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Hybrid Specialist Care Transitions-FT Days bei Centra Health, Inc

Centra Health, Inc · Lynchburg, Vereinigte Staaten Von Amerika · Hybrid

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Care transitions non-RN is responsible for the clinical aspects of determining the appropriate discharge plan for patients in the acute care setting. This member of the care transition team will be responsible for facilitating and coordinating a safe appropriate discharge plan while meeting the patient's individual needs as well as state and federal regulations. This position works collaboratively with multiple other disciplines throughout the organization and community.

Responsibilities

Coordinates patient care from admission to discharge in collaboration with RN and clinical team
 
Conducts a comprehensive patient/family assessment to ensure appropriate referrals to address psychosocial and socioeconomic needs
 
Identifies any barriers and provides clarity to determine realistic goals for the treatment plan
 
Demonstrates understanding of the patient's diagnosis/prognosis care needs and outcome goals of the treatment/care plan
 
Collaborates with IDT clinical team to develop transition of care plan
 
Patients have a discharge disposition assessed and plan initiated within hours of admission of scheduled workdays
 
Initiates and implements treatment plan modification through monitoring and re-evaluation to accommodate changes in treatment or progress
 
Communicates appropriate information between physicians, nursing units, administration and other disciplines to facilitate care transitions to ensure proper patient flow through the hospital system
 
Collaborates with other departments to ensure customer satisfaction and coordinate appropriate patient care
 
Works with the IDT clinical team to understand the patient's utilization plan, appropriateness of continued hospitalization, observation status, length of stay and quality issues
 
Demonstrates documentation to substantiate assessment planning implementing and evaluating of discharge plan in a clear concise organized timely manner
 
Identifies barriers to timely patient discharge and facilitates resolution of the barriers and appropriately reports non-acute days
 
Coordinates and provides hand off to other post-acute providers
 
Contributes to the overall LOS
 
Follows CMS guidelines with regards to observation notice (OBN) and inpatient notice (IMM)
 
Identifies patients requiring crisis intervention and acts as soon as possible to resolve the issue(s) and prevent barriers to patient flow

Qualifications

Required Education: Bachelors Degree in Social Work, Social Services, or Health Promotions
 
Required Experience: Computers skills a must as well as excellent communication and the ability to work collaboratively with other disciplines
 
Preferred Experience: Working knowledge of D/C planning, post acute services, or Medicare regulations
 
Required Certifications and Licensures: Hold a current, active American Heart Association Basic Life Support (AHA BLS) course completion card.
 
Preferred Certifications and Licensures: CCM Certification Care Coordination and Transitions Management Certification
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